Neurology key points

Question 1

Define primary vs secondary HA

Answer 1

Primary: biologic disorder of the brain. Secondary: identifiable organic causation

Question 2

Do primary or secondary HA often have clinical red flags?

Answer 2

Secondary

Question 3

Describe use of neuroimaging studies in patients w/ stable HA that meet criteria for migraines

Answer 3

Don’t need imaging

Question 4

Initial Mx of thunderclap HA?

Answer 4

CT head

Question 5

Mx of thunderclap HA when initial CT head is normal?

Answer 5

LP

Question 6

Etiology of most thunderclap HAs 2/2 SAH?

Answer 6

Rupture of previously unidentified saccular aneurysms. These account for 85% of SAH a/w thunderclap HA

Question 7

Initial drug used as stroke prevention s/p carotid and vertebral artery dissection?

Answer 7

ASA

Question 8

Idiopathic intracranial HTN is MC managed with what class of drug? Name 2 examples of drugs in this class

Answer 8

Carbonic anhydrase inhibitors. Examples: acetazolamide, topiramate (weak CA inhibitor effects)

Question 9

What treatment is highly effective in resolving HA 2/2 CSF leak that fail to respond to conservative management?

Answer 9

Epidural blood patching

Question 10

DOC for initial Mx of trigeminal neuralgia?

Answer 10

Carbamazepine

Question 11

Response rate for carbamazepine in trigeminal neuralgia?

Answer 11

> 50%

Question 12

What percentage of patients with trigeminal neuralgia don’t respond to medication? What form of Tx should you consider in these cases?

Answer 12

30%, surgical therapies

Question 13

In which patients should you consider medication overuse HA?

Answer 13

Those taking analgesics, ergotamines, or triptans more than 10 days per month

Question 14

What 2 classes of medications have very high rates of medication overuse HA and thus should be avoided in Mx of HA?

Answer 14

Opioids, butalbital compounds

Question 15

Usage of the POUND mnenomic can be helpful in proper Dx of migraine. What are these criteria, and how many are required for diagnosis of migraine?

Answer 15

If more than 3 of these criteria are fulfilled, patients can be Dx w/ migraine w/o further eval.

1. Pulsatile
2. One day in duration (episodes lasting 4-72 hr if unTx)
3. Unilateral
4. N/v
5. Disabling

Question 16

3 most effective medication classes for acute migraine therapy?

Answer 16

NSAIDs, triptans, dihydroergotamine

Question 17

What is the most cost-effective initial choice for acute migraine therapy?

Answer 17

NSAIDs

Question 18

What are the preferred NSAIDs and/or triptans in acute management of migraines?

Answer 18

There is no preferred drug in any of these classes

Question 19

There are 2 main criteria for use of preventive therapy in migraine HA patients. Meeting either of these suggests that you should use preventive agents. Name the two criteria

Answer 19

1. 8 or more total days of migraines per month

2. 4 or more days of disabling migraines per month

Question 20

3 drugs that are often successful in initial treatment of acute tension HA?

Answer 20

APAP, ASA, NSAIDs

Question 21

DOC for prevention of tension HA?

Answer 21

Amitriptyline

Question 22

What imaging should be performed in patients with suspected cluster HA? Why?

Answer 22

MRI brain, to r/o structural HA mimicking cluster HA

Question 23

2 first-line therapies for acute cluster HA?

Answer 23

1. Oxygen inhalation

2. SubQ sumatriptan

Question 24

Describe timeline of primary cough HA?

Answer 24

Develops abruptly after a cough, remains severe for seconds to minutes, then fades

Question 25

What drug does primary cough HA typically respond to?

Answer 25

Indomethacin

Question 26

Neuroimaging is indicated in patients with mild TBI only if they possess at least one of the following 6 characteristics. Name those characteristics

Answer 26

1. Repeated vomiting 2. Dysarthria 3. Worsening HA 4. Drowsiness 5. Persistant confusion 6. Focal neuro findings

Question 27

Name 3 reasons that CT is preferred to MRI in initial neuroimaging of TBI

Answer 27

1. Cheaper 2. More widely available 3. More sensitive in identification of skull Frx

Question 28

First step in management of an athlete suspected of sustaining mild TBI?

Answer 28

Remove them from play!

Question 29

When can an athlete suspected of sustaining mild TBI be allowed to play contact sports again? (2 requirements)

Answer 29

1. Return to cognitive baseline | 2. ASx and not requiring any meds to treat trauma-related Sx

Question 30

Patients in what age group have the highest rates of morbidity, mortality, and hospitalization s/p TBI?

Answer 30

Older than 75

Question 31

Name 3 preventive measures helpful in preventing TBI in patients older than 75

Answer 31

1. Avoid overmedication 2. Regular physical activity 3. Living area modifications

Question 32

Describe general management of postconcussive syndrome

Answer 32

Supportive/rehabilitative. Can direct medical Tx at specific Sx

Question 33

Describe prognosis of epidural hematoma without immediate surgical evacuation

Answer 33

Terrible- death often w/in hours

Question 34

Describe prognosis of epidural hematoma with immediate surgical evacuation

Answer 34

Excellent- bc underlying brain tissue is often uninjured

Question 35

Subdural hematomas commonly occur in the absence of significant trauma. This is particularly true in what 2 groups of patients?

Answer 35

1. Elderly | 2. Those taking anti-coagulants

Question 36

2 general modalities of Tx of subdural hematoma? (choice is dictated by presentation)

Answer 36

1. Obs | 2. Surgical evacuation

Question 37

Describe the major difference btwn simple and complex partial seizures

Answer 37

Both are partial (starting in one specific area of the brain). Simple partial don't have any change in consciousness, while complex partial have a disturbance in awareness

Question 38

Give 2 examples of semi-purposeful behaviors that can be seen during complex partial seizures

Answer 38

1. Lip smacking | 2. Finger fumbling

Question 39

Name 2 key differences in absence seizures vs complex partial seizures

Answer 39

Absence seizures are shorter (less than 5 sec, vs 30-90 sec) and are not associated with post-ictal confusion

Question 40

MC type of focal epilepsy?

Answer 40

Temporal lobe epilepsy

Question 41

Is the cause of most focal epilepsy found?

Answer 41

Nope

Question 42

Idiopathic generalized epilepsy is genetic and accounts for what fraction os all epilepsy syndromes?

Answer 42

1/3

Question 43

3 possible seizure manifestations of idiopathic generalized epilepsy?

Answer 43

1. Tonic-clonic 2. Absence 3. Myoclonic

Question 44

Juvenile myoclonic epilepsy is classically characterized by what? Name 2 additional types of seizures that can be present

Answer 44

Morning myoclonus. Other possibilities include tonic-clonic or absence seizures.

Question 45

2 components of immediate management of a seizure?

Answer 45

1. Stabilization of patient (attention to airway and VS) | 2. Rapid ID of any reversible causes

Question 46

Any patient with an unprovoked seizure should have neuroimaging. Which of these patients need an urgent CT w/o contrast? (3 characteristics)

Answer 46

Patients with any of the following require non-contrast CT to r/o a bleed. 1. Focal neuro deficits 2. Impaired mental status 3. Head trauma

Question 47

Management of a single provoked seizure?

Answer 47

Usually don't need AED. Instead focus on fixing the underlying cause.

Question 48

Dx of psychogenic non-epileptic seizure?

Answer 48

Inpatient video EEG